GOOD SHEPHERD OF DANVILLE

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met as evidence by: Based on observation and interview the above requirement was not met by Facility not having the requested records upon demand which poses an immedite health risk to residents in care.

Official plan of correction

By POC facility agrees to develop a filing system for all records and provide photos as well as documentation of what was implemented.

Deadline recorded: May 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)(13)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S2 not being associated which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2025 Plan of Correction S2 stopped working and agreed not to return until cleared. POC clear

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by converting the garage without prior notice/ approval which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2025 Plan of Correction By POC facility agrees to review the regulation and make updates as required and notify CCLD

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S2 not being trained prior to providing unsupervised care which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction By POC facility agrees to train S2 prior to leaving them unsupervised and notify CCLD

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in residents files being incomplete which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction By POC facility agrees to review all residents files and update them accordingly and notify CCLD

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies... maintained as follows:(2) Faucets...temperature ...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not as evidence by Based on observation the above requirement was not met by the shared bathrooms hot water measuring at 99.7 degrees F which poses an immedite health risk to residents in care.

Official plan of correction

By POC facility agrees to adjust the hot water to be within range and notify CCLD.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish... reports...to, the following:(1)A written report shall be submitted ...within seven days(D)Any incident which threatens the welfare,... of any resident. This requirement was not met as evidence by: Based on interviews, and record reviews, the facility did not comply with the section cited above by not reporting incidents to CCLD as required ehich posed a potential personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a)Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidence by: Based on interviews, and observation, the staff did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Backup Administrator also states that they will start documenting and providing disciplinary action to staff as needed.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include:(4)Personal assistance.. as indicated in the pre-admission appraisal, with ...bathing ... This requirement was not met as evidence by: Based on interviews, and record reviews, the facility did not comply with the section cited above by not providing resident with bathing as specified in their care plan which posed a potential personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(b)In addition … the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry … from incontinence This requirement was not met as evidence by: Based on interviews and record review the facility did not comply with the section cited above by not keeping R1 clean and dry from incontinence which posed a potential health , and personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Also facility agrees to maintain a log of all incotinence care provided with times and dates.

Deadline recorded: May 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on interviews the facility did not comply with the section cited above by not having adequete staff to respond to residents needs in a timely manner which posed a potential health, and personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Facility also hired additional staff and agrees to send CCLD an updated staff schedule.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

(a)In addition … residents …shall have all of the following personal rights:(1)To have …personal privacy in… communications…and meetings of resident and family groups. This requirement was not met as evidence by: Based on interviews and observation the facility did not comply with the section cited above by not providing privacy to residents which posed a potential personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, … This requirement was not met as evidence by: Based on interviews the facility did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

(a) Residents... have all of the following rights: (6) To care, ...that meet their individual needs ... by staff that are...competency to meet their needs. This requirement was not met as evidence by: Based on interviews, record reviews, and observations the facility did not comply with the section cited above by not providing resident with competent care which resulted in pressure injuries which posed an immediate health, and personal rights risk to persons in care.

Official plan of correction

Facility agrees to complete additional training for all staff by an approved vendor and notify CCLD upon enrollment. Resident was sent out to hospital and returned once injuries got better.

Deadline recorded: Jun 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, ..., or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care.

Official plan of correction

Administrator agrees to put resident on hospice or find new placement for resident.

Deadline recorded: Sep 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2024 Plan of Correction Administrator agrees to put resident on hospice or find new placment for resident.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observatio, the licensee did not comply with the section cited above in having a cleaning solution out in residents bathrooms which poses an immediate health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Facility Locked away cleaner

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having knives unlocked which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Facility Locked cabinet.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in not having an updated emergency disaster plan which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2024 Plan of Correction Adinistrator agrees to review and update Emergency Disaster plan and email a copy to CCLD

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above innot having done required disaster drills which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2024 Plan of Correction Administrator agrees to conduct the required drills document and notify CCLD

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having medications cabinet unlocked which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Facility locked cabinet

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. All individuals subject to a criminal record review... Obtain a California clearance...as required by the Department... This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, licensee did not comply with the section cited above by not having staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.

Official plan of correction

POC Due Date: 08/29/2024 Plan of Correction Staff Left facility.

Official classification

Type B

Official code

87608(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal,... Postural supports may be used under the following conditions.(2) Postural supports shall... permits quick release by the resident. This regulation is not met as evidence by: Based on interview and photos R1 was restrained in bed by a strap that was tied to bedrails which posed a potential health and personal rights risk to person in care.

Official plan of correction

Administrator has requested the correct support from the doctor and has stopped using the improper restraint.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation is not met as evidence by: Based on observation the dryer has an out of order sign and does not properly work. Staff has been hang drying clothes outside which poses a potental personal rights risk to persons in care

Official plan of correction

By POC date administrator agrees to purchase a new dryer and notify CCLD.

Deadline recorded: Aug 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidence by: Based on record review and interview the licensee did not comply with the regulation above by issuing an eviction letter because the resident was unhappy with the service which posed a personal rights violation to person in care.

Official plan of correction

By POC date administrator agrees to review the regulation and notify CCLD.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include:(3)Three nutritionally well-balanced meals...General Food Service Requirements. This requirement is not met as evidence by: Based on interviews and record review the licensee did not comply with the regulation above by not providing 3 balanced meals daily which posed a potential health risk to persons in care.

Official plan of correction

Administrator has retrained staff on what a balanced meal is.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...require such additional staff for the provision of adequate services. This requirement is not met as evidence by: Based on report of resident with previous elopement behavior eloping from facility the staff were not competent in how to address the behavior and prevent the resident from being missing for days.

Official plan of correction

By POC date administrator has agreed to install cameras to help monitor residents and will provide additional dementia training and submit proof of training's in accordance with regulations to CCLD

Deadline recorded: May 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidence by: Administrator did not have training records readily available for review upon LPA's request

Official plan of correction

By POC date administrator has agreed to provide all trainings and keep the training logs available at facility to meet regulation standards and notify CCLD

Deadline recorded: May 21, 2024. A deadline is not proof that correction was completed.